|
|
Help on Reffering a patient to a specialist
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Help on Reffering a patient to a specialist - December 17, 2003 7:15:00 AM
|
|
|
VagusX
Posts: 215
Joined: March 26, 2003
From: Savannah, GA, USA
Status: offline
|
Hey guys
I had a patient that has been coming to me off and on for about a year. I have seen her for bilateral shoulder bicipital tendonitis and most recently saw her for Bilateral lateral and medial epicondylitis.
She is a dental hygienist. Both her and I know that her symptoms are partially due to her job. She has been at it since the early 80's and she deals with her elbow pains daily from her first patient onto the last.
Our treatment consisted of everything that I know about epicondylitis and we were unable to get any relief. What I would like to discuss isn't Pt treatment options but more about her presentation and where to go from here.
For a few years now her joints have gotten very sore from activities (especially her job) and she has dealt with off and on contracture of the elbow and wrists. I'm not sure If I can really call it a contracture because they tend to resolve themselves in a cyclic manner. Her condition tends to not only affect her UE's but also her knees and ankles. She basically states that she gets very sore and her tendons begin to throb and her joints become stiff. Her UE are also extremely sensitive to WBing activities and carrying objects. She says that she has a hard time carrying her lunch bag due to elbow/shoulder pain so she tucks in her axilla so it doesn't put weight through her UE's.
I recommended that she get tested for rheumatoid. The results came back negative. I can pick up some OA in most joints but it is not severe. She has been treated with Cox-2 inhibitors and other antiinflamitories but she has reacted with rare side effects to Vioxx and is scared to experiment with others. She is able to take ibu and naproxen but gives minimal relief. She is currently taking glucosamine/chondoitin. She takes no other meds due to sensitivity and fear of side effects. She has recieved cortisone to her elbow 2 years ago and ended up having what she thinks to be an allergic reation. She reported that she was unable to straighten out her elbow for 2 weeks afterwards.
So I am thinking that we may be dealing with something that is beyond my scope of diagnosis. I would like to give her some ideas on a specialist that could deal with these symptoms. She has had a hard time finding a MD to really look into what is happening to her. She has dealt with General Practitioners and Orthopods so far. What sort of specialist would be best to deal with this sort of presentation?
Thanks
Dan in Savannah
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 17, 2003 7:39:00 AM
|
|
|
Andrew M. Ball PT PhD
Posts: 855
Joined: July 28, 2002
From: Charlotte, NC
Status: offline
|
Dan,
You may want to consider a few things:
Most PT's like to treat tennis elbow as though it's an elbow problem. Sometimes it is, but in the case of a dental hygenist, it's likely more a wrist problem --- have you immobilized the wrist with a splint for a few days?
There can also be radial nerve compression at the arcade of froshe, are you sure there is no nerve damage? What did your NCV screening show?
A certified hand therapist may be of help in fully assessing this patient clinically, be they PT or OT.
Some DC's have had success with cold laser treatment --- but that assumes that one is okay with a DC treating tennis elbow --- I'm not.
Hope that helps . . .
Drew
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 18, 2003 11:33:00 AM
|
|
|
Dr.Wagner
Posts: 1242
Joined: January 24, 2003
From: Indianapolis
Status: offline
|
VERY doubtful she is allergic to cortisone, likely it was mechanically due to the injection itself. Her fears about treatment need to be truly discussed with her doc, and LIKELY amplified by the patient herself.
Without seeing the tests that were ordered, further workup for systemic inflammatory arthritis is worthwhile. Rheumatoid Factor, if that what was ordered, is not terribly sensitive.
IT is EXTREMELY difficult to assess this case as it is an acute worsening of a chronic condition. If you are running out of ideas, talk to the Primary Care Doc about referral to a Rheumatologist or Sports Med or Hand Specialist Doc.
Honestly, from what you describe, a Rheumatology consult is appropriate.
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 19, 2003 2:03:00 AM
|
|
|
Sebastian Asselbergs
Posts: 1204
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
Why not check out the cervical spine in detail? With a bevy of bilateral "itis"-es, it may be prudent to consider neural issues - especially regarding her work positions. It is rather rare to find true bilateral "itis"-es! The joint stiffness may be secondary to muscle splinting, which may be secondary to neural irritation at lower cervical levels or at scalenes. Careful positional myotomal testing and ULNT may shed some light.
Sebastian
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 21, 2003 2:43:00 AM
|
|
|
FLOrthoPT
Posts: 85
Joined: October 20, 2003
From: wellington, fl, usa
Status: offline
|
I had one girl with similar problems and it turned out she had a somewhat rare connective tissue disorder. She presented with similar aches and pains, and she had hypermobility all over the place. She had 3 or 4 shoulder surgeries to help tighten her shoulders, but eventually, I and she both realized that something else must be going on. So I referred her out and after seeing a whole bunch of doctors, she had a rheumotologist that figured this out. Ask a rheumatologist to rule out Pseudoxanthoma elasticum,Ehlers-Danlos syndrome, etc. All though 99 out of 100 times it is something treatable like neural tension, etc, don't forget it can be some sort of connective tissue disorder.
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 21, 2003 9:54:00 AM
|
|
|
slp
Posts: 8
Joined: December 19, 2003
From: Kansas City, Missouri USA
Status: offline
|
I am a DC student who has worked with a DC who is board certified in orthpedics. He did a three year residency in ortho after chiro school. He also is board certified in pain management by the American Academy of Pain Management. He is not the "typical" chiro. He treats NMS disorders ethically and conservatively. He is also certified to do manipulation under anesthia. He is very good at what he does. If you would like I could give you his phone number and you could at least talk to him via the phone to get some ideas on this patient. He also has a couple of MD orthopods that work in his practice. He has a mutlidisciplinary practice. If you want to see his website you can look it up under a search engine. Look up: Lawson Orthopedic and Pain Management Centers. He is located in Austin, Texas. Hope that helps.
By the way, to the person who talked about cold laser therapy. Do you not like DC's? I feel that there are good and bad ones out there, just as there are good and bad PT's out there. I know of several DC's that are very good orthopedists, but they have taken the time to get the education after school. I myself will be doing the same thing. I also spend time once a week with the orthopedic department at KU Medical Center, which will only add to my diagnostic and SOME treatment skills in the future. Don't knock every DC. We are good people, we know our stuff. The DC's who are straight DC's (believe in the whole subluxation thing), well that is another group that I am not apart of.
You might also look into getting a cervical spine study done, MRI would be best. EMG might be helpful as well. I remember at KU in clinic we had a patient present somewhat similiar to your patients case and the MRI showed a slight disc herniation at C4/C5. The EMG was also helpful in the diagnosis. Just my $0.02 worth.
[This message has been edited by slp (edited December 21, 2003).]
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 22, 2003 6:09:00 AM
|
|
|
MD/DC
Posts: 6
Joined: December 21, 2003
Status: offline
|
Shawn, with all due respect to chiropractic orthopods, (I have a couple of close friends who are by the way), they didn't do a residency. The program is a weekend seminar series, and is in no way equivalent to an orthopedic surgery residency.
Furthmore the AAPM does not board certify anyone. They credential practicioners without requiring any specialized training or fellowship on the basis of a written exam and recommendation letters from colleagues.
To become truly "board certified" in pain management means obtaining an MD or DO degree, completing a residency in Neurology, Physical Medicine and rehabilitation or Anesthesiology, and then doing an approved one year fellowship.
[This message has been edited by MD/DC (edited December 22, 2003).]
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 22, 2003 6:39:00 PM
|
|
|
UTDC
Posts: 222
Joined: December 21, 2003
Status: offline
|
Vagus, sorry to hijack your post, I hope your patient is doing better.
Shawn,
MD/DC is absolutly right, a DABCO and an orthopedist are WORLDS (and many, many years) apart.
Drew,
We've had a few conversations (email) over the last few years and for most part, I think we agree on the big issues...except...
You continue to state that DC's should:
1) Not treat soft tissue injuries.
2) Not treat non-spinal conditions.
3) Not prescribe therapeutic exercises
If this is what you believe, than my question is what is left? Should DC's simply go about spinal manipulation day in and day out without thought to anything else? Can you imagine anything more mundane?
If this is the case, than I would have to respectfully disagree. Spinal manipulation is not exactly rocket science (neither is treating lateral epicondylitis for that matter), if that were going to be the limit of our scope/expertise than I think that DC programs could be cut down to about 6 months.
So how about rethinking your stand on the issue and maybe we can find even more common ground between the 2 professions.
Thanks,
Jeff
|
|
|
|
|
Re: Help on Reffering a patient to a specialist - December 22, 2003 7:41:00 PM
|
|
|
VagusX
Posts: 215
Joined: March 26, 2003
From: Savannah, GA, USA
Status: offline
|
Thanks everybody for the replys.
I'm informing her about some of the tips that people have shared on this posting.
I am telling her to take a look into finding a Rheumatologist first off. Although she has had a test already for Rheumatoid I found through then net that only about 80% of people that are tested for RA show Rheumatoid Factor. I believe the 20% who don't test positive for the RF and are seronegative, whereas the positive RF factor patients are seropositive.
I also did some research on some leads that I got from Ptupdate.com. Seronegative inflamitory arthritis and polymaigia rheimatica both looked like posinilities.
I appreciate all of the ideas on assessment and treatment. Unfortunately at this time she out of my hands. I have already had over 20 visits with her. She was very nonresponsive to treatment. Even the most conservative of therapies would aggrevate her symptoms. The only thing that actually did anything for her pain was phono with hydrocortisone and I have a funny feeling that time was the real factor and her symptoms where simplied becoming less inflamed.
I still feel that her job is a major contributing factor in flareups but she is just a mess. I have never worked on a person with so many "itis's." Exercises were very tedious. Working on one joint would inflame another and she would end up being misirable for a few days if we did too much.
I didn't spend a ton of time on her neck becasue I could never find anything striking. I don't have the expertise that some of you guys have on determining whether neural tissue is a factor. ULTT was positive for median but I couldn't deciefer if that was coming from her elbow or wrist with enough accuracy. So I move on and look to find something more concrete. In this case, I found nothing. I then look to other options and try to learn new ways to treat in the mean time.
As far as having her see a Chiro. I would be very careful in doing this. I don't know any chiros yet in my area that aren't "snap happy." Her neck is so sensitive that a strong maipulation would send her through the roof. I think anyways she has already seen one and the treatment was inneffective. I wouldn't mind letting her see an enlightened DC but I have yet to meet one in my area. If any DC's on this board know any well-rounded DC's in the Savannah area I would appreciate your input.
I will keep everybody here posted on what is found.
Thanks
Vagus
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
 Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.078
|
Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> Help on Reffering a patient to a specialist 
